Form-Individual Intake

Individual Intake Form

Leslie Root Counseling
Date

MonthDayYear
Date
Emergency Contact Name and Phone
Client Name First and Last
Spouse/Partner Name
Address

Address

Street Address Line 2

CityState/Zip

Postal / Zip Code
Telephone- Home: ( )
Work
Email
example@example.com
Sex

MaleFemale
Age blank
DOB
Marital/ Relationship Status

Significant OtherSingle (never married)cohabitatingFirst marriageSeperatedDivorcedWidowedRemarried (after divorce)Remarried (after spouse's death)
Current Employment:

Full-timePart-timeHome MakerUnemployedFull-time studentPart-time studentRetired
How did you hear about us?
Please list children, including age, gender and if they live with you etc.
Highest level of Education attended
Race/Ethnicity
List current medications and amounts including past prescriptions for mental health
4445 WEST 77TH ST, SUITE 201, EDINA, MN 55435

651/485/1151 www.LESLIEROOTCOUNSELING.COM
Medical History: Are you taking any medications?

noyes
If so what medications are you currently taking
Name and address of physician
Have you ever been hospitalized?

yesno
If hospitalized for what conditions?
Have you ever been treated for chemical dependency

yesNo
If so, for what?
Have you ever had legal consequences as a result of your chemical or alcohol use DUI etc

yesno
Do you have concerns about your alcohol or chemical use?

yesNo
Please describe any marriage or relationship stressors
CHILDREN: Do any of your children have any physical, emotional or mental conditions now or
CHILDREN: Do any of your children have any physical, emotional or mental conditions now or in the past that the therapist needs to be aware of?
in the past that the therapist needs to be aware of?

REASON(S) FOR SEEKING COUNSELING:
Briefly describe the problem for which you wish to have counseling.
4445 WEST 77TH ST, SUITE 201, EDINA, MN 55435

651/485/1151 www.LESLIEROOTCOUNSELING.COM
What would you like to see happen as a result of counseling?
What concerns you the most right now?
Adapted from AAMFT Forms Book - I.-2

4445 WEST 77TH ST, SUITE 201, EDINA, MN 55435

651/485/1151 www.LESLIEROOTCOUNSELING.COM
Should be Empty:

Individual Intake Form